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Patient Assistance Information

MYOBLOC Reimbursement Support Program

Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
> Patient insurance requirements have not been specified and income requirements have not been disclosed. Patients must have a medically appropriate condition/diagnosis and be a US citizen.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. Applications can also be completed online or downloaded.
> Doctors and patients must both complete a section of the application and sign.
> Not specified
Ship To
> Not specified
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
Myobloc (botulinum toxin type B)
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader